Internal Medicine Coding Alert

Question: The internist excised an "uncertain behavior" neoplasm from a patient's skin. Five days later, the patient returns, and the internist discovers during a pre-op exam that the neoplasm is now malignant. The physician wants to bill 99214 in addition to a prolonged-service code for that visit. Should we not bill the visit because of the global period, or should I bill the codes with modifier 24?


California Subscriber

Answer: If the internist provided the pre-op exam for an unrelated surgery, you should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) and attach modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code.

The physician's discovery of the lesion's morphology alone is not significant enough to count that as separate from the pre-op visit. You should report the appropriate prolonged-service code (99354-99360) only if you have documented the extra time the physician spent with the patient. For instance, if the physician spent an hour and 25 minutes with the patient, you could report 99214 (... Physicians typically spend 25 minutes face-to-face with the patient and/or family) and +99354 (Prolonged physician service in the office or other outpatient setting...; first hour [list separately in addition to code for office or other outpatient evaluation and management service]).